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Analysis shows facilities can learn much from each other in regard to
the right way and wrong way to prevent wrong-site surgeries

HARRISBURG, Pa., Jan. 10 /PRNewswire-USNewswire/ -- While reports of
wrong-site surgeries in the Commonwealth have decreased during 2007, some
facilities continue to report wrong-site surgeries that may have been
prevented had they followed protocols implemented by other Pennsylvania
facilities that have been successful in preventing wrong-site surgeries in
their institutions, according to analysis published by the Patient Safety
Authority in its December 2007 Patient Safety Advisory.

Since the Authority first published the frequency of wrong-site
surgeries in Pennsylvania in its June 2007 Patient Safety Advisory, a more
in-depth analysis of facilities was conducted that shows some facilities
are doing the right things to prevent wrong-site surgery, while others
still have system weaknesses that make wrong-site surgery a possibility.

The Authority visited six volunteer hospitals. Four of the hospitals
had more than one report of a wrong-site surgery within a two and a half
year time period and two hospitals had no reports of a wrong-site surgery
during the reporting period. The Authority's team consisting of the
Pennsylvania Patient Safety Reporting System's clinical director and two
nurse analysts spent one day at each of the six facilities with a
confidentiality agreement consistent with Act 13.

"From our recent observations, wrong-site errors usually result from
either misinformation prior to the patient getting into the operating room
or misperceptions of hospital staff once the patient is in the operating
room," Dr. John Clarke, clinical director of the Patient Safety Authority
said. "Misperception can occur from confusion regarding right or left and
the failure to question authority, among other reasons."

Clarke added that there were several variations among facilities about
how they interpreted and implemented the Joint Commission's Universal
Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
Considerable differences also occurred in how information prior to surgery
was verified, how surgical sites were marked, and how time outs were done,
as well as in all other steps when taking the patient through the operating
room.

"We noted that wrong-site surgery errors were associated with the
failure to identify incorrect information in the documents related to
surgery, such as the schedule, consent and patient's history and physical
examination [H &P] before the operation," said Clarke. "Hospitals that
check for errors at every opportunity have more success in preventing
misinformation from reaching the operating room--and the more independent
the checks the better."

Clarke added that verification of the patient's information should be
done with questions that require active answers, e.g. what arm are we
operating on?, as opposed to questions that require passive answers e.g.
we're operating on your left arm, right?

"Our observations led us to appreciate that the mark on the site to be
operated on represents the patient's voice after he or she is sedated or
anesthetized," Clarke said. "The mark should be made with the help of the
patient or patient advocate and should be made before the patient is
sedated."

Other observations in regard to the site marking include that the mark
should be made accurately and in a way consistent with the facility's
protocol; the mark should be consistent with all documents completed prior
to surgery; the mark should be made by someone who knows about the
procedure and hospital protocol; and the mark should not be made with an
"X" or something else that can be easily misinterpreted.

For more information on appropriate site markings and the complete
findings from the six facility site visits, go to the article "Insight into
Preventing Wrong-Site Surgery" of the 2007 December Patient Safety Advisory
at http://www.psa.state.pa.us.

Facilities interested in learning more to prevent wrong-site surgery
can also go to the Authority's website for more information that includes:
A graph of cumulative wrong-site surgery events in Pennsylvania which will
be updated quarterly; stand alone copies of figures discussing the flow and
awareness of information in the operating room; the ongoing comparative
results of detailed reports of wrong-site surgery and near misses, updated
quarterly; a stand-alone copy of a self-assessment checklist for programs
to prevent wrong-site surgery; access to all Patient Safety Advisory
articles regarding wrong-site surgery; previously released "Doing the
'Right' Things to Correct Wrong-Site Surgery" video; and a contact link to
discuss with the Authority's PA-PSRS team your assessments, successes,
failures, other experiences, opinions and questions.

The Authority's quarterly 2007 December Advisory contains more articles
developed from data submitted through real events that have occurred in
Pennsylvania's healthcare facilities. The articles also provide advice and
prevention strategies for facilities to implement within their own
institutions. Highlights of this and other articles include:

Preventing MRSA: More than 1,700 reports related to
methicillin-resistant Staphylococcus aureus (MRSA), including 14 deaths,
have been reported to the Authority since June 2004 through October 2007.
The reports show that in 90 percent of the cases, a MRSA screening was not
noted as having been done when the patient was admitted to the facility. In
about 13 percent of reports where MRSA was found upon admission, the
information about the infection was not communicated to other healthcare
workers. Additional prevention tips for patients can be found on the
Authority's website at http://www.psa.state.pa.us under "Consumer Tips."

Problems Associated with Regional Nerve Blockers: The interscalene
block (ISB) is a regional anesthetic technique that provides pain relief to
the shoulder and lateral regions of the arm and forearm. However, the
Authority has received reports of the complications associated with the
nerve block that includes: chest pain, chest tightness, seizure, irregular
heartbeat and ineffective pain control. Proper technique can reduce these
complications.

Drug Overdoses Still Happen with Smart Infusion Pump Technology: Even
when computerized systems are used to reduce drug overdoses they sometimes
still occur, particularly with intravenous high-alert medications like
Heparin. One of the most common reasons for the overdose is due to
misprogrammed infusion pumps.

CT Scans May Affect Pacemakers and other Implantable Electronic
Devices: The Authority has received reports of patients experiencing a
shock during a CT scan if they have an implantable electronic device (e.g.
Pacemaker). The interference may be due to new, more powerful scanners
being used to obtain a faster scan.

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